The Red Queen in Lewis Carroll’s “Alice in Wonderland” told Alice, “Now here, you see, it takes all the running you can do to keep in the same place. If you want to get somewhere else, you must run at least twice as fast.” Welcome to our world. I first used this allegory in my presidential address at Digestive Disease Week© 2015 and it remains relevant today.
There are some harsh realities of U.S. health care that will affect the GI field in the next decade. Currently, the U.S. spends $3 trillion ($9,534/per person) on health-related costs, representing 17 percent of the gross domestic product (GDP). This will rise to $5 trillion (21 percent of GDP) by 2025. Concomitantly, first-dollar payments have shifted more to individuals through copays and high deductibles. No longer will insurance payments shield people from the high cost of health care. Price sensitivity and a demand for higher value will spur development of lower-cost services, telehealth and other technologies that will disrupt current care processes.
The single greatest challenge we will face in GI will be the shift in reimbursement from fee for service — favoring our high-margin endoscopic procedures — to payments for coordination of care, where efficient resource use is paramount. While painful, we can absorb a 10 percent reduction in payments per procedure. It is more difficult to absorb a 10 to 30 percent reduction in patient or procedure numbers as primary-care managers eliminate low-value referrals. Elimination of unnecessary procedures will occur rapidly as we move to value-based payments and block reimbursement for defined populations.
Can our specialty adapt and financially thrive in a period of reduced per click care and an increasing emphasis on management of complex patients?
In response to regulation, economic challenges and mandated electronic medical record use, GI practices have been consolidating or migrating to large Clinically Integrated Networks (CINs). CINs typically include a hospital network, an employed primary-care base, affiliated or owned specialists, ancillary facilities, and a payor/insurance partner. We are beginning to see multi-state CINs and regional health-system oligopolies. Successful CINs will focus on maximizing individual patients’ experiences, efficiently managing high-cost episodes of care and coordinating care of patients with complex multi-organ diseases — remember 5 percent of patients account for 50 percent of all health-care spending. Academic centers can lead this innovation if they understand how to use big data to identify at-risk patients, develop data-driven clinical-care algorithms,1 and achieve patient-focused, easy-access multi-specialty care coordination. Innovations in this area likely will come as much from the technological world as the medical world.
Gastroenterologists will survive by providing high-quality consultative and procedural care. Specialists who thrive will provide low-cost, clinically effective options for people and populations that currently suffer from disorganized care that varies in quality and outcomes. Three focus areas in GI include CRC prevention and management of IBD, and cirrhotic patients.
CRC management will move from disparate efforts focused on enhancing screening and increasing adenoma-detection rates to an organized health-system goal of cancer prevention2,3 with emphasis on cost reduction. Care of an IBD patient population will rest on a foundation of guideline-driven medical care, but expand to a multi-disciplinary model that integrates psychosocial care,4 remote monitoring,5 machine learning,6 and a financial risk-bearing specialty medical home.7 Similarly, cirrhotic patients cared for within a large CIN will be identified by administrative data and segregated into different populations — compensated versus uncompensated for example — with different resources proactively deployed according to their medical and social needs.8
Gastroenterology has enjoyed financial halcyon days based on high-margin, low-risk procedural reimbursement. Can our specialty adapt and financially thrive in a period of reduced per-click care and an increasing emphasis on management of complex patients, where we must demonstrate population-level health value? I believe so. Henry Ford said, “There are no big problems, just a lot of little problems.” Begin to enhance care in discreet and digestible portions, with a goal of adding these small efforts up to something beautiful.
Avedis Donabedian was the father of the modern “health-care quality” movement. Toward the end of his life, he — although a data-driven scientist — reflected on what remains truly important. He said, “Health care is a sacred mission … a moral enterprise and a scientific enterprise but not fundamentally a commercial one. Doctors and nurses are stewards of something precious. Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can then work backwards to monitor and improve the system.”
If we are to keep medicine balanced among science, compassion and efficiency and regain joy in our profession, we will need new leaders who understand both direct patient care and health-system concerns. It is time to teach the business of medicine in between lessons about large-polyp resection or ablation of Barrett’s dysplasia.
Dr. Allen has no conflicts to disclose.
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2. Lee, J.K., Levin, T.R., Corley, D.A. The road ahead: what if gastroenterologists were accountable for preventing colorectal cancer? Clin Gastroenterol Hepatol. 2013 Mar; 11(3): 204-7.
3. Saini, S.D., et al. Colorectal cancer screening quality measures: beyond colonoscopy. Clin Gastroenterol Hepatol. 2016 May; 14(5): 644-7.
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5. Atreja, A., et al. Impact of the mobile HealthPROMISE platform on the quality of care and quality of life in patients with inflammatory bowel disease: study protocol of a pragmatic randomized controlled trial. JMIR Res Protoc. 2015 Feb 18; 4(1): e23.
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7. Regueiro, M.D., McAnallen, S.E., Greer, J.B., et al. The inflammatory bowel disease specialty medical home: a new model of patient-centered care. Inflamm Bowel Dis. 2016; 22: 1971-1980.
8. Regueiro, M.D., McAnallen, S.E., Greer, J.B., et al. Linking a hepatology clinical service line to quality improvement. Clin Gastroenterol Hepatol. 2015; 13: 1391-1395